2015-599-E Solid Waste - Summit Design and Engineering Services landfill survey

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DocuSign Envelope ID: B1 D50716-7603-4905-88E6-3348AF487601 ACOR" DATE(MM/DD/YYYY) Ill CERTIFICATE OF LIABILITY INSURANCE 11/2/2015 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Ellen Walker NAME: Business Insurers of Carolinas PHONE No . (919)968-4611 FAX No: (919)968-8991 800 Eastowne Drive, Suite 208 ADODRESS:ewalker @business-insurers.com PO BOX 2536 INSURER(S)AFFORDING COVERAGE NAIC# Chapel Hill NC 27515-2536 INSURERA:Ohio Security A XV 24082 INSURED INSURERB:Peerless Indemnity Ins Co A XV 18333 Summit Design And Engineering Services Pllc INSURERC:Ohio Casualty Ins Co A XV 24074 504 Meadowlands Dr INSURER D: INSURER E: Hillsborough NC 27278 INSURER F: COVERAGES CERTIFICATE NUMBER:CL1533112595 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LIMITS LTR INSR WVD POLICY NUMBER MM/DD/YYYY MM/DD/YYYY GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED 300 000 X COMMERCIAL GENERAL LIABILITY PREMISES Ea occurrence $ A CLAIMS-MADE FxI OCCUR BKS55764212 1/1/2015 1/1/2016 MED EXP(Any one person) $ 15,000 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER PRODUCTS-COMP/OP AGG $ 2,000,000 POLICY X PRO LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident $ 1,000,000 B X ANY AUTO BODILY INJURY(Per person) $ ALL OWN ED SCHEDULED A8907831 4/2/2015 4/2/2016 BODILY INJURY(Per accident) $ AUTOS AUTOS X HIRED AUTOS X NON-OWNED PROPERTY DAMAGE $ AUTOS Per accident Experience Mod Factor 2 $ X UMBRELLA LAB X OCCUR mb excess over GL,Auto & EACH OCCURRENCE $ 6,000,000 C EXCESS LAB CLAIMS-MADE WC AGGREGATE $ 6,000,000 DED I X I RETENTION$ 10,000 US055764212 1/1/2015 1/1/2016 $ A WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS'LIABILITY Y/N X TORY LIMITS ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 1,000,000 OFFICER/MEMBER EXCLUDED? N/A (Mandatory in NH) WS55764212 1/1/2015 1/1/2016 E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Orange County Solid Waste Management ACCORDANCE WITH THE POLICY PROVISIONS. PO Box 17177 Chapel Hill, NC 27516 AUTHORIZED REPRESENTATIVE Ellen Walker/ELLEN � � ACORD 25(2010/05) ©1988-2010 ACORD CORPORATION. All rights reserved. IN S025(9ninns)ni The arnRn name and Innn arc rcnie4crcfl marine of arnpin